Provider Demographics
NPI:1407965320
Name:WALLACE, KATHRYN MARY (APRN, BC)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MARY
Last Name:WALLACE
Suffix:
Gender:F
Credentials:APRN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2640 HAMSTROM RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-3832
Mailing Address - Country:US
Mailing Address - Phone:219-762-4423
Mailing Address - Fax:219-763-3120
Practice Address - Street 1:2640 HAMSTROM RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-3832
Practice Address - Country:US
Practice Address - Phone:219-762-4423
Practice Address - Fax:219-763-3120
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000473A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200056120AMedicaid
IN500004228OtherRAILROAD MEDICARE
S57554Medicare UPIN
IN200056120AMedicaid